JAWDA Guidelines for Bariatric Surgery (BS) January 2019 1
Table of Contents Executive Summary... 3 About this Guidance... 4 Bariatric Surgery Indicators... 5 Appendix A: Glossary... 19 Appendix B: Approved procedure CPT codes:... 20 Appendix C: Minor Complications ICD-10 and CPT Codes:... 21 Appendix D: Major Complications ICD-10 Codes... 22 2
Executive Summary The Department of Health Abu Dhabi (DOH) is the regulatory body of the healthcare sector in the Emirate of Abu Dhabi and ensures excellence in healthcare for the community by monitoring the health status of its population. The Emirate of Abu Dhabi is experiencing a substantial growth in the number of hospitals, centers and clinics. This is ranging from school clinics and mobile units to internationally renowned specialist and tertiary academic centers. Although, access and quality of care has improved dramatically over the last couple of decades, mirroring the economic upturn and population boom of Emirate of Abu Dhabi, however challenges remain in addressing further improvements. The main challenges that are presented with increasingly dynamic population include an aging population with increased expectation for treatment, utilization of technology and diverse workforce leading to increased complexity of healthcare provision in Abu Dhabi. All of this results in an increased and inherent risk to quality and patient safety. DOH has developed dynamic and comprehensive quality framework in order to bring about improvements across the health sector. This guidance relates to the quality indicators that DOH is mandating the quarterly reporting against by the operating general and specialist hospitals in Abu Dhabi. The guidance sets out the full definition and method of calculation for patient safety and clinical effectiveness indicators. For enquiries about this guidance, please contact jawda@doh.gov.ae This document is subject for review and therefore it is advisable to utilize online versions available on the DOH website at all times. Published: January 2019, Version 1 3
About this Guidance The guidance sets out the definitions and reporting frequency of JAWDA Bariatric Surgery (BS) performance indicators. The Department of Health (DoH), with consultation from local and international expertise of obesity and weight management, has developed Bariatric Surgery Performance Indicators that are aimed for assessing the degree to which a provider competently and safely delivers the appropriate clinical services to the patient within the optimal period of time. The Bariatric Surgery performance indicators in this guidance include measures to monitor morbidity and mortality in patients undergoing bariatric surgery I.e. (postoperative complications, readmissions, re-operation, and extended length of stay). Healthcare providers are the most qualified professionals to develop and evaluate quality of care for obesity and weight management patients; therefore, it is crucial that clinicians retain a leadership position in defining performance among Bariatric healthcare providers. Who is this guidance for? All DoH licensed healthcare facilities providing bariatric surgery services in the Emirate of Abu Dhabi. How do I follow this guidance? Each provider will nominate one member of staff to coordinate, collect, monitor and report Bariatric services quality indicators data as per communicated dates. The nominated healthcare facility lead must in the first instance e-mail their contact details (if different from previous submission) to JAWDA@doh.gov.ae and submit the required quarterly quality performance indicators through Jawda online portal. What are the Regulation related to this guidance? Legislation establishing the Health Sector DOH Standard for Obesity and Weight Diagnosis, Pharmacological and Surgical Management Interventions As per DoH Policy for Quality and Patient Safety issued January 15 th 2017, this guidance applies to all DOH Licensed Hospital Healthcare Facilities in the Emirate of Abu Dhabi in accordance with the requirements set out in this Standard. 4
Bariatric Surgery Indicators Indicator Number: BS001 KPI Description (title): Exclusion Reporting Frequency: comparison if available Rate of Minor Complications among Low-Risk Patients within 30 days from Primary principal Bariatric Surgery Patient Safety Complication Rate of minor medical/surgical complications among low risk primary principle bariatric surgery patients (18 years or older) within 30 days of the surgery date. Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low-risk bariatric surgery patients (18 years or older) who have undergone a primary principal bariatric surgery and had a minor complication within 30 days of the principal bariatric surgery. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Minor Complication Codes: ICD-10 CPT Included CPT Excluded K28 - K28.9; 43235-43236; 43239; K56.7; 43259 K91.89 43245 R11.2 96360; 96361 N39.0 E86.0 96360; 96361 N17.8; N17.9 96360; 96361 90935; 90937; 90945; 90947 N19 90935 N20.0 K43.2 T81.4xxx 96360; 96361 Low Risk adult patients (18 years and above) with a primary principal bariatric procedure Patient who are considered as high risk at the time of surgery as defined in Appendix A. Patients who have undergone revisional surgery. Patients who were discharged against medical advice (AMA) Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 5
Indicator Number: BS002 KPI Description (title): Rate of Minor Complications among High-Risk Patients within 30 days from Principal Bariatric Surgery Patient Safety Complication Rate of minor medical/surgical complications within 30 days of the surgery date among high-risk bariatric surgery patients (18 years or older). Numerator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery and had a minor complications within 30 days of the principal bariatric surgery. Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery. Bariatric Surgery CPT Codes: 43644-43645, 43659, 43775, 43846-43847, 43848, 43999 Exclusion Reporting Frequency: comparison if available Minor Complication Codes: ICD-10 CPT Included CPT Excluded K28 - K28.9; 43235-43236; 43239; K56.7; 43259 K91.89 43245 R11.2 96360; 96361 N39.0 E86.0 96360; 96361 N17.8; N17.9 96360; 96361 90935; 90937; 90945; 90947 N19 90935 N20.0 K43.2 T81.4xxx 96360; 96361 Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. Patients who were discharged against medical advice (AMA) Low-risk cases Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 6
Indicator Number: BS003 KPI Description (title): Rate of Major Complications among Low-Risk Patients within 30 days from Primary Principal Bariatric Surgery Patient Safety Complication Rate of major medical/surgical complications within 30 days of the primary principal surgery date among low risk bariatric surgery patients (18 years or older). Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low risk patients (18 years or older) who have undergone a primary principal bariatric surgery and had a major complication(s) within 30 days of the primary principal bariatric surgery. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Major Complication Codes: ICD-10 CPT Included CPT I82 code range series 34001; 34051; 34101; 34111; 34151; 34201; 34203; 34401; 34421; 34451, 34471, 34490; 37620 Z98.0;T82.533; T85.598; 44602; 44604; 49320 T85.638A L02.91; Z98.0 10030; 10080 10120; 11000 Excluded 11042-11047; 99601; 99602; 11044 K92.2 36430; 36440; 36444; 36450; with blood transfusion K56.49 - K56.52; K56.60; 44180; 44602; 44604; K56.5 49320 K63.1 44602; 44604; 49320 K43.0 35902; 43281; 43282 I21.01-29; I22.1-9; I23.0-.8; I25.2 I63.00 I63.9 N17.8; N17.9; N19;N18.1 90935; 90937; 90945; N18.9 90947 J96.0-J96.9 31500; 94660-94662 R11.2 99601; 99602 K91.3; K95.89 43775; 43848 T81.4xxx 10040-10180; 11000-11047 7
Exclusion Reporting Frequency: comparison if available Low-risk adult patients (18 years and above) with a primary principal bariatric surgery Patients considered as high risk at the time of surgery as defined in Appendix A. Patients who have undergone revisional surgery. Patients who are discharged against medical advice (AMA). percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 8
Indicator Number: BS004 KPI Description (title): Rate of Major Complications among High-Risk Patients within 30 days from Principal Bariatric Surgery Patient Safety Complication/Outcome Rate of major medical/surgical complications within 30 days of the surgery date among high-risk bariatric surgery patients (18 years or older). Numerator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery and had a major complication(s) within 30 days of the principal bariatric surgery. Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery. Bariatric Surgery CPT Codes: 43644-43645, 43659, 43775, 43846-43847, 43848, 43999 Major Complication Codes: ICD-10 CPT Included CPT I82 code range series 34001; 34051; 34101; 34111; 34151; 34201; 34203; 37620 Z98.0; T82.533; T85.598; T85.638A L02.91; Z98.0 10030; 10080 10120; 11000 11047; 99601; 99602; K92.2 36430; 36440; 36444; 36450; Blood transfusion K56.49 - K56.52; K56.60; 44180; 44602; 44604; K56.5 49320 44602; 44604; 49320 Excluded 11042-11044 K63.1 44602; 44604; 49320 K43.0 35902; 43281; 43282 I21.01-29; I22.1-9; I23.0-.8; I25.2 I63.00 I63.9 N17.8; N17.9; N19; N18.1 90935; 90937; 90945; N18.9 90947 J96.0-J96.9 31500; 94660-94662 R11.2 99601; 99602 K91.3; K95.89 43775; 43848 T81.4xxx 10040-10180; 11000-11047 Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. 9
Exclusion Reporting Frequency: comparison if available Patients who are discharged against medical advice (AMA) Low-risk cases percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 10
Indicator Number: BS005 KPI Description (title): Re-operation Rate among Low-Risk Patients within 30 days from Primary Principal Bariatric Surgery Patient Safety Complications Re-operation rate among low-risk patients 18 years old or older within 30 days from primary principal bariatric procedure surgery. Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low- risk patients (18 years or older) who had a re-operation within 30 days of the primary principal bariatric surgery. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Exclusion Reporting Frequency: comparison if available Reason for RTOR ICD-10 CPT Leak Z98.0; T82.533; T85.598; T85.638A Stricture / Bowel Obstruction K56.49; K56.50; K56.51; K56.52; K56.60; K56.5 44602; 44604; 49320 Perforations (non-traumatic) K63.1 Severe Wound Infection T81.32 10030 Incision & Drainage, Skin, Sub- Q and Accessory Structures 10040 10180; 11000 11047 Low-risk adult patients (18 years and above) with a primary principal bariatric surgery Patient who are considered as high risk at the time of surgery as defined in Appendix A. Patients who have undergone revisional surgery. Patients who are discharged against medical advice (AMA) Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 11
Indicator Number: BS006 KPI Description (title): Re-operation Rate among High-Risk Patients within 30 days from Principal Bariatric Surgery Patient Safety Complications Re-operation rate among high-risk patients (18 years old or older) within 30 days from principal bariatric procedure surgery Numerator: Total number of high-risk patients (18 years or older) who had a reoperation within 30 days of the principal bariatric surgery. Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery. Bariatric Surgery CPT Codes: 43644, 43645, 43659, 43775, 43846, 43847, 43848, 43999 Exclusion Reporting Frequency: comparison if available Reason for RTOR ICD-10 CPT Leak Stricture / Bowel Obstruction Perforations (nontraumatic) Z98.0; T82.533; T85.598; T85.638A K56.49; K56.50; K56.51; K56.52; K56.60; K56.5 K63.1 Severe Wound Infection T81.32 10030 Incision & Drainage, Skin, Sub-Q and Accessory Structures 44602; 44604; 49320 10040 10180; 11000 11047 Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. Patients who are discharged against medical advice (AMA) Low-risk cases Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 12
Indicator Number: BS007 KPI Description (title): Unplanned Hospital Readmission among Low-Risk Patients within 30 days of the Primary Principal Bariatric Surgery Patient Safety Complications Percentage of low-risk bariatric patients (18 years or older) who had an unplanned hospital readmission within 30 days of the primary principal bariatric surgery encounter discharge date. Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low risk patients (18 years or older) who had an unplanned hospital readmission within 30 days of the primary principal bariatric surgery encounter discharge date. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Exclusion Reporting Frequency: comparison if available Low-risk adult patients (18 years and above) with a primary principal bariatric surgery Patient who are considered as high risk at the time of surgery as defined in Appendix A Patients who undergoing revisional surgery. Patients who are discharged against medical advice (AMA) Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 13
Indicator Number: BS008 KPI Description (title): Unplanned Hospital Readmission among High-Risk Patients within 30 days of the Principal Bariatric Surgery Patient Safety Complications Percentage of high-risk bariatric patients (18 years or older) who had an unplanned hospital readmission within 30 days of the principal bariatric surgery encounter discharge date. Numerator: Total number of high-risk patients (18 years or older) who had an unplanned hospital readmission within 30 days of the principal bariatric surgery encounter discharge date. Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery Bariatric Surgery CPT Codes: 43644, 43645, 43659, 43775, 43846, 43847, 43848, 43999 Exclusion Reporting Frequency: comparison if available Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. Patients who are discharged against medical advice (AMA) Low risk cases Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 14
Indicator Number: BS009 KPI Description (title): Death Rate among Low-Risk Patients within 30 days from Primary Principal Bariatric Surgery Patient Safety Complications Rate of death within 30 days following the primary principal bariatric surgery among low-risk patients 18 years or older. Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low-risk patients (18 years or older) who died within 30 days of the primary principal bariatric surgery. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Exclusion Reporting Frequency: comparison if available Low-risk adult patients (18 years and above) with a primary principal bariatric surgery. Patients who are considered as high risk at time of surgery as defined in Appendix A. Patients who have undergone revisional surgery. Patients who are discharged against medical advice (AMA) Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 15
Indicator Number: BS010 KPI Description (title): Death Rate among High-Risk Patients within 30 days from Principal Bariatric Surgery Patient Safety Complications Rate of death within 30 days following the principal bariatric surgery among high-risk patients (18 years or older). Numerator: Total number of high-risk patients (18 years or older) who died within 30 days of the principal bariatric surgery Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery. Bariatric Surgery CPT Codes: 43644, 43645, 43659, 43775, 43846, 43847, 43848, 43999 Exclusion Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. Patients who are discharged against medical advice (AMA) Low-risk cases Reporting Frequency: comparison if available Percentage Developed locally by modifying similar indicators used by AHRQ, OECD, CQC, and MBSAQIP Hospital patient data source, bariatric registry 16
Indicator Number: BS011 KPI Description (title): Extended Length of Stay (LOS) > 7 days among Low-Risk Primary Principal Bariatric Surgery Patients Process Patient centered care The percentage of low-risk patients (18 years or older) undergoing primary principal bariatric surgery who had an extended postoperative LOS (>7 days). Primary Principal Procedure: The most complex bariatric operative procedure performed during this OR encounter AND the first metabolic or bariatric procedure for the patient to ever undergo. Numerator: Total number of low-risk patients who experienced extended length of stay (> 7 days) following the primary principal bariatric procedure. Denominator: Total number of low-risk patients (18 years or older) who have undergone a primary principal bariatric surgery. Bariatric Surgery CPT Codes: 43644,43645, 43659, 43775, 43846,43847, 43999 Exclusion Reporting Frequency: comparison if available Low-risk adult patients (18 years and above) with a primary principal bariatric surgery Patient who are considered as high risk at the time of surgery as defined in Appendix A. Patients who have undergone revisional surgery. Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry, claims. 17
Indicator Number: BS012 KPI Description (title): Extended Length of Stay (LOS) > 7 days among High-Risk Bariatric Surgery Patients Process Patient centered care The percentage of high-risk patients (18 years or older) who have undergone a principal bariatric surgery and had an extended postoperative LOS (>7 days). Numerator: Total number of high-risk patients (18 years or older) who experienced an extended length of stay (> 7 days) following the principal bariatric procedure Denominator: Total number of high-risk patients (18 years or older) who have undergone a principal bariatric surgery. Exclusion Low-risk cases Reporting Frequency: comparison if available Bariatric Surgery CPT Codes: 43644, 43645, 43659, 43775, 43846, 43847, 43848, 43999 Patients who are considered as high risk at the time of the principle bariatric surgery as defined in Appendix A. Patients who have undergone a revisional surgery. Percentage Developed locally by modifying similar indicators used by MBSAQIP Hospital patient data source, bariatric registry 18
Appendix A: Glossary Term Definition Low Risk No previous metabolic or bariatric surgical procedures (regardless of approach). Does not meet any of the high risk criteria below. High Risk To be considered high-risk, the patient must meet any one or more of the following criteria: Revisional surgery BMI >50 (Z68.43, Z68.44, Z68.45) H/O Venous Thromboembolism (VTE) (Z86.718) Severe Obstructive Sleep Apnea (OSA) (G47.33) Poor Functional Status (Z74.09) H/O Acute Myocardial Infarction (AMI) (AMI I21, I22 and I23 range and I25.2) H/O Percutaneous Coronary Intervention (PCI) (PCI Z98.61) H/O End Organ Damage (N18.1 N18.9) Transplant (Z94.0 - Z94.7 and Z94.81 Z94.89) Age >55 yrs. Primary Surgery The first metabolic or bariatric procedure ever performed on the patient. Principal Surgery The most complex bariatric operative procedure performed during this OR encounter. Revisional Any re-operative metabolic or bariatric surgery (regardless of approach). Surgery 19
Appendix B: Approved procedure CPT codes: CPT Description 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) 43659 Unlisted laparoscopy procedure, stomach 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g. Gastric band and subcutaneous port components) 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e. Sleeve gastrectomy) Gastric restrictive procedure with partial gastrectomy, pylorus-preserving 43845 duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) 43999 Unlisted procedure, stomach 20
Appendix C: Minor Complications ICD-10 and CPT Codes: Minor Complication ICD-10 CPT Included CPT - Excluded Marginal Ulcer diagnosed K28 - K28.9; K56.7; 43235-43236; with endoscopy 43239; 43259 Anastomotic Stricture K91.89 43245 Requiring Endoscopic dilatation Nausea / Vomiting R11.2 96360; 96361 Urinary Tract Infection N39.0 (UTI) Dehydration E86.0 96360; 96361 Acute Renal Failure managed w/ IV fluids - no N17.8; N17.9 96360; 96361 90935; 90937; 90945; 90947 hemodialysis Unspecified Kidney Failure N19 90935 Kidney stone N20.0 Incisional Hernia K43.2 Trocar surgical site infection managed with drainage & local wound care T81.4xxx 96360; 96361 21
Appendix D: Major Complications ICD-10 Codes Complication ICD-10 CPT Included CPT - Excluded Venous Thrombembolism (VTE) requiring administration of anticoagulant or intervention, such as embolectomy or inferior vena cava (IVC) filter Anastomotic Leak requiring reoperation Percutaneous drainage of abscess, stent placement, or conservative management with parenteral nutrition or NPO Gastrointestinal hemorrhage requiring transfusion or intervention I82 code range series 34001; 34051; 34101; 34111; 34151; 34201; 34203; 34401; 34421; 34451, 34471, 34490; 37620 44602; 44604; Z98.0; T82.533; T85.598; T85.638A 49320 L02.91; Z98.0 10030; 10080 10120; 11000 11047; 99601; 99602; K92.2 36430; 36440; 36444; 36450; with blood transfusion 11042-11044 Small bowel obstruction with reoperation K56.49 - K56.52; 44180; 44602; K56.60; K56.5 44604; 49320 Bowel perforation with reoperation K63.1 44602; 44604; 49320 Trocar site hernia requiring reoperation K43.0 35902; 43281; 43282 Myocardial infarction (AMI) I21.01-29; I22.1-9; I23.0-.8; I25.2 Cerebrovascular accident (CVA) I63.00 I63.9 Renal Failure requiring dialysis N17.8; N17.9; 90935; 90937; N19; N18.1 N18.9 90945; 90947 Respiratory failure requiring intubation J96.0-J96.9 31500; 94660-94662 Chronic nausea and vomiting not responsive to conservative management and requiring total parenteral nutrition (TPN) R11.2 99601; 99602 Gastric sleeve stenosis/obstruction requiring revision to gastric bypass Surgical site infection (SSI superficial, deep or organ space) requiring debridement, washout in the operating room, or percutaneous intervention K91.3; K95.89 43775; 43848 T81.4xxx 10040-10180; 11000-11047 22